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RESEARCH ARTICLE
Is quality of care during childbirth consistent
from admission to discharge? A qualitative
study of delivery care in Uttar Pradesh, India
Malvika Saxena, Aradhana Srivastava, Pravesh Dwivedi, Sanghita BhattacharyyaID*
Research Department, Public Health Foundation of India, Gurugram, Haryana, India
*sanghita@phfi.org
Abstract
Background
Improving quality of maternal healthcare services is key to reducing maternal mortality
across developing nations, including India. Expanding access to institutionalized care alone
has failed to address critical quality barriers to safe, effective, patient-centred, timely and
equitable care. Multi-dimensional quality improvement focusing on Person Centred Care
(PCC) has an important role in expanding utilization of maternal health services and reduc-
ing maternal mortality.
Methods
Nine public health facilities were selected in two rural districts of Uttar Pradesh(UP), India, to
understand women’s experiences of childbirth and identify quality gaps in the process of
maternity care. 23 direct, non-participant observations of uncomplicated vaginal deliveries
were conducted using checklists with special reference to PCC, capturing quality of care
provision at five stages—admission; pre-delivery; delivery; post-delivery and discharge.
Data was thematically analysed using the framework approach. Case studies, good prac-
tices and gaps were noted at each stage of delivery care.
Results
Admission to maternity wards was generally prompt. All deliveries were conducted by skilled
providers and at least one staff was available at all times. Study findings were discussed
under two broad themes of care ‘structure’ and ‘process’. While infrastructure, supplies and
human resource were available across most facilities, gaps were observed in the process of
care, particularly during delivery and post-delivery stages. Key areas of concern included
compromised patient safety like poor hand hygiene, usage of unsterilized instruments;
inadequate clinical care like lack of routine monitoring of labour progression, inadequate
postpartum care; partially compromised privacy in the labour room and postnatal ward;
and few incidents of abuse and demand for informal payments.
PLOS ONE | https://doi.org/10.1371/journal.pone.0204607 September 27, 2018 1 / 20
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OPEN ACCESS
Citation: Saxena M, Srivastava A, Dwivedi P,
Bhattacharyya S (2018) Is quality of care during
childbirth consistent from admission to discharge?
A qualitative study of delivery care in Uttar Pradesh,
India. PLoS ONE 13(9): e0204607. https://doi.org/
10.1371/journal.pone.0204607
Editor: Alexandra Sawyer, University of Brighton,
UNITED KINGDOM
Received: May 10, 2018
Accepted: September 11, 2018
Published: September 27, 2018
Copyright: ©2018 Saxena et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
files.
Funding: This work was supported by Grant
number - OPP1127467, URL - https://www.
gatesfoundation.org/. The funders had no role in
study design, data collection and analysis, decision
to publish, or preparation of the manuscript.
Competing interests: The authors have declared
that no competing interests exist.
Conclusions
The study findings reflect gaps in the quality of maternity care across public health facilities
in the study area and support the argument for strengthening PCC as an important effort
towards quality improvement across the continuum of delivery care.
Introduction
In the past decade, maternal and newborn survival has been at the top of global health agenda,
and plays a crucial role in the overarching health goals of the Millennium Development Goals
(MDGs), and more recently, the Sustainable Development Goals 2030 (SDGs) [1]. As a result
of concentrated global advocacy and action focusing largely on increased access to institutional
care, the proportion of deliveries attended by skilled birth attendants in developing countries
rose from 57% in 1990 to 70% in 2014 [2]. However, this increase has not translated into the
desired reduction of maternal mortality, with an estimated 302, 000 deaths still occurring glob-
ally every year, almost 99 percent of which occur in lower and middle income countries [3].
Institutionalized care with increased access alone has failed to address the critical barriers in
providing quality care that is safe, effective, patient-centred, timely and equitable [4,5].
Quality of care (QoC) encompasses the dimensions of structure, process and outcome of
care, each aspect requiring equal emphasis for holistic improvement in QoC [6–8]. Person-
centered care (PCC) is a critical component of QoC, as it focuses on the care that is respectful
of and responsive to individual patient preferences, needs, and values and ensuring that patient
values guide all clinical decisions [7]. PCC has been addressed using different terminologies
such as patient, person, client, individual and are often used interchangeably in describing
health care [9]. Recently there has been a shift from a care that supports disease-centred care
to more on person-centred care where individuals are viewed as central to the decision making
process and are free to exercise their rights as patients. Whereas the former type of care focuses
primarily on the clinical aspect of the care giving less importance to other related aspects of
care like respect; dignity, privacy, confidentiality, informed choices etc [10,11]. PCC is crucial
for sustained utilization of maternal health services and to maximize health access and out-
comes, especially in contexts of socio-economic, ethnic and cultural diversities [12]. The recent
movement towards a composite approach in quality of maternity care has highlighted the need
for improving the experience of women as an important dimension, despite this aspect of care
being difficult to measure objectively [13]. The personal interaction between the woman and
provider is important in shaping her experience and perception of clinical care [14,15]. Wom-
en’s perspectives of maternity care that influenced their care-seeking behaviour ranged from
poor staff attitudes; lack of amenities; perceived poor quality of health care facilities. Other
reported barriers to effective utilization of maternity services were cost of care; poor access to
health facility and health services being not available at odd hours [16–19]. Experience of ver-
bal and physical abuse, negative provider attitude, poor information sharing and lack of emo-
tional support from providers could be detrimental to utilization of maternity services [14,20].
In particular, India has witnessed a sharp surge in institutional delivery from 39% in 2005–
06 to 79% in 2015–16 with the implementation of the nationwide conditional cash transfer
program—Janani Suraksha Yojana (JSY) under the National Health Mission (NHM) in 2005
[21]. Despite this, reductions in maternal mortality have been limited [21–24]. This is attrib-
uted to gaps in the clinical quality of facility-based maternal care [25,26]. Recent evidence also
points to women experiencing delays, neglect, abuse and poor client-provider communication
Quality of maternal care during childbirth in India
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Abbreviations: CHW, Community Health Worker;
FHR, Fetal Health Rate; JSY, Janani Suraksha
Yojana; MDGs, Millennium Development Goals;
MIL, Mother-In-Law; MMR, Maternal Mortality
Ratio; MOIC, Medical Officer In-Charge; NHM,
Nation Health Mission; NMR, Neo-natal Mortality
Rat; PCC, Person Centred Care; PNC, Post-Natal
Care; QoC, Quality of Care; SDGs, Sustainable
Development Goals; UP, Uttar Pradesh; WHO,
World Health Organization.
during childbirth, leading to delayed care, and jeopardizing the likelihood of future utilization
of facility-based care [21,27–30,31]. QoC in Indian policies and programs has fallen short at
addressing the quality gaps in providing care that is more responsive to patient’s needs and
ultimately leads to better outcomes [32,33].
Few studies have examined continuity of care and assessed women’s experiences through-
out her process of care. Consequently, we conducted direct, non-participant observations of
the process of maternity care as experienced by women delivering in public health facilities in
UP throughout their stay at the facility. The objective of the research was to understand the
quality of care that was provided to women during childbirth in health facilities and identify
associated gaps in the process of maternity care.
Materials and methods
We conducted 23 qualitative direct, non-participant observations of uncomplicated vaginal
deliveries in primary and secondary level public health facilities between October 2016 and
February 2017. After completing 23 observations data saturation was achieved and it was
decided to discontinue further data collection to avoid redundancy. The direct observation
approach helped in gaining first-hand, in-depth information on the quality of delivery care, in
addition to capturing complex and multiple patient-provider interactions.
Analytical framework
Our analysis is guided by Donabedian’s Quality framework and the World Health Organiza-
tion’s (WHO) Quality of Care Framework for maternal and newborn health [6,34]. The
results section is organised based on Donabedian framework of broad themes of care ‘struc-
ture’ and ‘process’. Donabedian defines Structure as the organisational and professional
resources associated with the provision of health care (e.g. staffing; facility infrastructure; avail-
ability of medicines and staff training) and Process as how the care is given ie the things done
to and for the patient (e.g. technical quality; experience of care). The WHO framework with its
eight domains of quality of care informed the sub-themes (Fig 1). Infrastructure refers to the
physical structures like buildings including arrangements for water and electricity, Human
resources refers to the number and configuration of hospital staff; their competency levels; level
of supervision; staff training, Supplies refers to medical and non-medical equipment/supplies
in the hospital, Clinical process of care refers to adherence to the standard operating procedures
for providing health care to patients, Patient safety refers to provision of health care which is
safe and minimises risks and harm to service users, Information sharing refers to the provider-
client information exchange for the purpose of diagnosis and the determination of preference
for treatment, Emotional support refers to the access to one’s own social and emotional support
and the psychosocial support given by the provider, Privacy refers to observance of patient’s
privacy from others at all time, Respectful care refers to the way provider treats his/her patients
throughout the process of care. The additional sub-themes are defined as Promptness refers to
how quickly the care is provided; reducing delays in providing care, Cleanliness refers to the
general cleanliness maintained in the hospital, Informal payment refers to the incidences of
providers asking for payment including cash; in-kind or any kind of gifts under the table. The
analytical framework also guided the tool development.
Study setting
The observations were conducted across nine public health facilities in two districts of UP, in
northern India. UP is the most populous state of India, but has some of the poorest health indi-
cators. UP has the second highest Maternal Mortality Ratio (MMR) and the third highest neo-
Quality of maternal care during childbirth in India
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natal mortality rate (NMR) in the country, 285 and 49 respectively [35], compared to 167 [36]
and 28 at the national level [37]) respectively. The study districts of Kanpur Nagar and Unnao
were purposively selected for ease of access as both are neighbouring the state capital, Luck-
now. Kanpur Nagar has a high proportion of urban population (65.83%) while Unnao has
much lower urbanization (17.1%) and is primarily a rural district [38,39]. Of the two, Kanpur
Nagar fairs relatively better on the MCH indices with 76% institutional deliveries (69% in
Unnao) and 79% deliveries assisted by skilled personnel (71% in Unnao) when compared to
the state averages of 68% and 70% respectively [40–42].
Study sites
A list of all public health facilities (CHCs and PHCs) with similar levels of care were obtained
and a total of nine facilities were randomly selected. These facilities were previous sites of a
Fig 1. Analytical framework of QoC themes for facility-based maternity care across five stages of child birth. Broad themes of
care ‘structure’ and ‘process’ in the analytical framework have been informed by Donabedian’s Quality framework. The WHO
framework with its eight domains of quality of care informed the sub-themes. Three additional emerging sub-themes emerging from
the data were included. The analytical framework was used for data analysis and guided the tool development. Abbreviation: QoC
Quality of Care.
https://doi.org/10.1371/journal.pone.0204607.g001
Quality of maternal care during childbirth in India
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large scale maternal health trial for the implementation of WHO Safe Childbirth Checklist. A
list of range of primary and secondary level facilities was included with an attempt to under-
stand providers’ and system-level challenges specific to both levels and ensure heterogeneity in
the data for wider implications. [S1 Table]
Study facilities ranged from 4–30 bed units, 2–3 delivery tables; all labour rooms had elec-
tricity with backup; 5 out of 9 labour rooms had a functional new born stabilization unit. Fil-
tered potable water and hospital meals were being provided in two and four health facilities
respectively. With respect to the availability of human resources across facilities there were
about a minimum of 1 to a maximum of 5 Lady Medical Officers; 4 to 9 staff nurse and ANMs
and 1 to 3 other support staff like sweeper in position. The patient load for vaginal deliveries in
the month of September 2016 ranged from as low as 110 to 257 with an average of 179 deliver-
ies being conducted across the centres.
Study instruments
A pre-tested facility observation checklist was used to capture women’s experience of labour
and delivery care at five different stages of delivery care—Admission; Pre-Delivery/Initial
Examination; Delivery; Post-Delivery and Discharge. The checklist, adapted from national
public health standards and maternal and newborn health guidelines. The checklist was not
pre-validated and had 114 items describing the normal sequence of actions that would follow
at every stage of institutional delivery as per the Indian standards of care [43–45]. Checklist
items reflected the content (technical competency of provider, availability of supplies etc.) as
well as the process (information shared, emotional support, promptness) with a focus on ele-
ments of quality of person-centred care [S2 Table]. For instance to understand the process of
care a checklist item inquired about whether initial examination was done within 15 minutes
after registration; woman told how far along she was in labour; woman face any abuse during
labour etc. The observer could enter yes/no for every observation point, in addition to docu-
menting open-ended comments about significant observations regarding quality of care that
would support in understanding the case in greater detail.
Data collection
Data was collected by a four member team of two clinically trained nurses and two social sci-
entists. The nurse focused on the clinical aspect whereas the social scientists were capturing
person centred aspect of care. Prior to data collection, the investigators were trained on the
technique of direct, non-participant observation, checklist contents and expected details to be
captured. Training included practice observations using the checklist, on which the senior
researchers gave feedback to improve quality and depth of data recorded. The investigators vis-
ited each facility for a period of 4–5 consecutive days to conduct the observations. The team
was stationed at the facility from morning to evening; eight night-time deliveries were also
observed. Data collection at each facility was initiated by a formal introduction with the Medi-
cal Officer In-charge (MOIC) to explain the purpose of the project and brief the MOIC about
the intended data collection plan. This was followed by a facility tour for familiarization with
the staff and facility layout.
Informed verbal consent was obtained from all relevant staff prior to data collection. In
order to minimize inherent biases of observation on provider behaviour (Hawthrone effect),
one to two observations were conducted without formal recording, however there is a possibil-
ity of researcher bias as observations of behaviour are subjective in nature. To reduce this effect
a team of two trained nurses and two social scientists were asked to conduct observation for
each case simultaneously and later the observation checklist was matched for any marked
Quality of maternal care during childbirth in India
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discrepancy. The providers were assured that data collection was anonymous and individual
performance would not be reported or published. In order to minimize changes to specific
aspects of behaviour, the providers were briefed broadly about the overall observation proce-
dure without sharing details of individual checklist items.
Pregnant women and their attendants visiting the facility for childbirth were randomly
approached and the purpose of the observation was explained to them in a manner that other
people present in the room could not listen to the conversation. Informed verbal consent was
then taken from participating women (and family members in some cases) prior to starting
the observation. A door-to-door approach was followed, meaning the same woman was
observed at all five stages of delivery care from admission through discharge. Each observation
lasted for about 8 to 12 hours and the same woman was followed until the end of the day and
the observation continued the next day to capture the discharge procedure. There were no
refusals, though there were a few cases where women had to be dropped from the observation
process, as they were referred out of the facility. In two emergency situations the investigators
had to intervene in order to assist the staff with arranging for the delivery.
At the end of each day, the entire research team discussed and completed a final checklist
after comparing data from individual checklists and coming to a consensus on final data
points. Open-ended comments from all four members were carefully included in the final
checklist. The completed and approved paper-based checklists were transferred to soft-form
by the study team.
Ethical approval and consent to participate. This study obtained ethical approval from
the University of California, San Francisco (153312) and the Institutional Ethics Committee of
the Public Health Foundation of India (TRC-IEC-276/15). In which the study received ethics
committee approval for obtaining verbal consent. Verbal consent was documented in a partici-
pant log maintained by the observation team. A written permission from the State Mission
Director, National Health Mission was obtained for undertaking the study in the selected facil-
ities. Approval was also taken from the Chief Medical Officers of the two districts before com-
mencing data collection.
Analysis
Based on our analytical framework, data from the checklist was organized under the two broad
themes (structure and process) and then further categorized into sub-themes including: infra-
structure; human resource; supplies; clinical process of care; patient safety; information shar-
ing; emotional support; respectful care and privacy. Additional sub-themes (informal
payment, promptness and cleanliness) emerging from the observations were also identified
and included in the framework. Percentage observations for each checklist item were calcu-
lated using MS Excel 2010 which are discussed here as ‘few’ (below 25%); some (25–49%);
many (50–74%) and most (above 74%). Content from open-ended comments and notes sec-
tion of all the checklists was thoroughly reviewed and indexed using the study framework.
Narratives from the observations reflecting critical quality gaps across different stages of deliv-
ery care were also identified and presented as case-studies.
Results and discussions
The results are organized under two broad domains of quality, specifically ‘structure’ and ‘pro-
cess’ for each of the five stages of care during childbirth. The first domain (‘structure’) encom-
passes the organizational aspects of care: infrastructure; supplies and human resource. The
second domain (‘process’) describes the behavioural and technical aspects of care: promptness,
emotional support, information sharing, clinical process of care, patient safety; cleanliness,
Quality of maternal care during childbirth in India
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informal payments and privacy. We describe the process of care across five stages from admis-
sion to discharge for all the 23 cases.
Stage 1: Admission
A uniform admission procedure was followed across all nine facilities. The staff nurses on duty
at the maternity unit were responsible for admission or referral of the women on the basis of
preliminary physical examination. Women reaching the facility for delivery were usually
accompanied by a Community Health Worker (CHW) and one or more relatives. The labour-
ing women were taken straight to the labour room, where the nurse conducted a physical
examination and determined whether the baby could be delivered at the facility or needed
referral to a higher level facility. In the meantime, male attendant(s) (usually a husband), was
directed to the registration counter located in the common admission area of the facility to
obtain a registration slip. At night, the nurse issued the registration slip, as the registration
counter was closed. In cases of referrals, a referral slip was provided; a mandatory written con-
sent from the husband was obtained and an ambulance was arranged.
No wheel chair or stretcher was available for taking most women into the maternity unit
and in few cases they had to be carried by their companions. The first physical examination
included measuring cervical dilation, time of contraction and determining position of the foe-
tus. While taking medical history, most providers also enquired about onset of labour and
membrane rupture. As per the Government of India’s Maternal and Newborn Health national
guidelines for all women in labour (cervix 4 cm) plotting contractions, Fetal Heart Rate
(FHR), maternal pulse, color of amniotic fluid every 30 mins; plotting temperature, blood
pressure and cervical dilation in cms every 4 hours is recommended. Although blood pressure,
FHR was measured for some women however, pulse and body temperature were not measured
even once for majority of the cases. The waiting time for admission for most women did not
exceed 15 minutes. None of the women or companions were asked for informal payments at
this stage.
Stage 2: Pre-delivery
The second observation stage spanned from the time the women were admitted to the mater-
nity unit until they were shifted to the labour room for delivery. The examination took place in
the labour room as there was no separate examination room in maternity units of any facility.
The maternity unit in all facilities had a common ward for prenatal, as well as postnatal
women. Most women spent close to 6–7 hours or more in the maternity unit prior to delivery.
During this period, women were mostly observed walking around, squatting or sitting on the
floor in the lobby area outside the labour room. In the event that a woman needed to rest, she
would use the beds in the postnatal (PNC) ward.
Monitoring the progress of labour was limited to conducting cervical dilation exam ranging
from once (in the first one hour) to a maximum of four times prior to delivery. Most of the
times the providers were called to check the progression when the woman faced increasing
pain or contractions. Only a few providers washed their hands and cleaned the woman’s peri-
neum before conducting vaginal examination. None of the providers were observed maintain-
ing partograph or any record of labour progression and instead relied on cervical dilation
exam also called the ‘two finger test’/’per vaginal’ test. Close to half the women observed were
not monitored at all prior to delivery, after the first physical examination at the time of admis-
sion. After performing cervical dilation exam, providers briefly informed women and compan-
ions about how long it would take for the delivery to happen. Providers ensured partial privacy
of women during physical examination as all examinations were performed in the labour
Quality of maternal care during childbirth in India
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room. Though screens were available in labour rooms of most facilities, they were not being
used for maintaining inter-patient privacy. Most women were accompanied by at least one
female companion during the initial examination, who stayed with them during the pre-deliv-
ery stage. However, in a few cases women were left alone and unattended for periods longer
than 15 minutes prior to delivery. None of the women or companions were asked for informal
payments prior to delivery. Box 1 reflects to the poor clinical process of care being provided to
pregnant woman in one of the facilities under study.
Stage 3: Delivery
The third stage of observation was that of the delivery. Only a few women had to wait for more
than 15 minutes before being shifted to the labour room once they were ready for delivery
(fully dilated). It was observed that majority of the labour rooms had two to three delivery
tables and well-equipped with power back-up to enable night time deliveries during power
cuts. Most deliveries were performed by the staff nurse, assisted by one or more staff and the
CHW. In addition to the CHW, all providers allowed at least one female birth companion with
the women during delivery who could be the mother/mother-in-law or sister/sister-in-law.
Companions of nearly half of the women were asked to purchase medicines (mostly oxytocin)
and other supplies from nearby pharmacies located outside the facility. These included, syrin-
ges, blade, sanitary pads, soap and cloth for wiping the woman and her baby. Delivery of each
woman was conducted on a separate delivery table. Almost all providers supported normal
delivery by providing perineum support and good coaching in terms of emotional, physical
and informational support, resulting in few episiotomies, however only a few women were
allowed to deliver in the position they desired. The providers in most cases did not help the
women climb onto or get down from the delivery table and mostly supported by her compan-
ions. Some women were left unattended for more than 15 minutes in the labour room.
With regard to patient safety, providers in nearly all cases used sterile surgical gloves for
examining the women, though only in a few cases they performed hand hygiene prior to that.
In many cases blades (used for cutting the umbilical cord) were reused after washing in bleach-
ing solution. Other instruments were washed under running water and seldom soaked in
decontamination solution after use. Delivery tables were wiped after each delivery was per-
formed with the cloth brought by the women without use of any disinfectant. Most providers
disposed the contaminated waste in leak-proof containers. However, all sharps were either left
on the table or thrown on the floor, to be cleared by the sweeper later on, while the women
were still lying on the delivery table.
Box 1. Clinical process of care
After conducting the previous delivery, the nurse was on the terrace (open area next to
the maternity unit). Meanwhile, the woman (already present on the terrace) started
vomiting profusely and within no time laid flat on the ground and delivered the baby.
The nurse came running and said: “why didn’t you tell me; I am standing here
only. . .you fool!” The baby kept lying on the floor for about 2 mins, after which the
nurse and sweeper brought the supplies. CHW and Mother-in-law were standing beside
the woman but none of them picked up the baby from the floor. The sweeper held the
baby, cleaned it with a cloth, and placed the baby on the mother’s abdomen. After which
she clamped and cut the cord using a blade, and the nurse gave an oxytocin injection to
the woman.
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As per the Government of India’s Maternal and Newborn Health national guidelines 10 IU
of oxytocin IM must be administered within 1 minute of birth for normal labour and delivery.
However, in half of the cases women were administered a uterotonic (oxytocin 1ml to 3 ml)
prior to delivery for inducing labour pains and all injections were given without disinfecting
the skin. The umbilical cord was clamped using a sterile clip in case of most deliveries. Imme-
diate uterine massage was given to most women following delivery of placenta. Assessment for
complete removal of placenta and membranes, as well as for perineal and vaginal lacerations
was not carried out for close to half of the cases. Likewise, immediate postpartum care includ-
ing taking vital signs, administering antibiotics and palpating the uterus was not performed
for more than half of the cases. Most women were not exposed unnecessarily at any point dur-
ing delivery.
Most babies were wiped and covered using a piece of cloth brought by the women’s fami-
lies; the nose and mouth were cleaned using the same cloth. The birth weight was recorded
either immediately or at a later time for most babies delivered. Immediate skin-to-skin contact
was established for close to two-thirds deliveries. Most providers did not check baby’s temper-
ature within 15 minutes of birth.
A few women were physically and verbally abused (talking roughly, pushing, pulling, slap-
ping on thigh) by the providers including assistant staff, in the process of delivery. For instance
pulling/pushing the woman on the delivery table for adjusting position; shouting at her and/or
slapping on the thigh when the woman doesn’t seem to follow the instructions given by the
provider; giving undue fundal pressure; ask her to go to some other hospital if not willing to
follow provider’s instructions. This would generally happen in spite of the presence of the
companions and ASHA worker. A few instances of demand for informal payments were also
observed, where the staff asked for money before handing the baby to the women and their
companions. Box 2: reflections pointing to an instance of informal payment being demanded
from the woman’s family before handing the baby to the mother.
Table 1 lists the important indicators performed by the providers during procedure and
post-procedure for all the 23 cases that were observed across all nine facilities.
Stage 4: Post- delivery
The fourth stage of observation spanned from the time the women were shifted to the PNC
ward until their discharge. In all cases women were kept under observation in the labour room
for 45 to 60 minutes after delivery. They were examined for bleeding and shifted to the PNC
ward, once their condition was stable. During this time the companions would arrange for tea
and snacks (mainly biscuits) for the women and staff. The PNC stay for most women ranged
from 6–10 hours in case of day time deliveries and up to 24 hours in case of late night
Box 2. Informal payment
The nurse placed the baby on the weighing machine uncovered and un-wiped and
demanded money from the mother-in-law (MIL). The MIL placed 25 INR on the
machine but the nurse was not happy with it and said: “are you not ashamed of offering
such a low amount of money to me?” Then the MIL placed 10 INR more and said: “we
are poor people and we have only this much to offer.” The nurse got angry and left the
baby and money on the machine and left the room saying: “I don’t need this money. If
you are poor then keep this money as you will need it”.
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deliveries. The PNC ward of most facilities was located close to the nurse duty room and facili-
tated monitoring of women in the ward.
PNC wards in all the facilities were equipped with beds, electricity (with backup), toilets
and drinking water supply mostly hand-pumps. There was no restriction on the number of vis-
itors or companions allowed inside the PNC ward, often making the ward too crowded during
visiting hours. The presence of male visitors in the PNC ward impeded privacy during breast-
feeding. Although all women and babies got a separate bed during their stay in the PNC ward,
there was no arrangement for companions, who either shared the bed with the women or slept
on the floor. The bed cots and bedsheets were clean in almost half of the facilities. However,
toilets were found to be dirty and the light fixtures were often missing or faulty. Hospital meals
for the women were available in close to half of the facilities.
Staff worked in shifts of 10–24 hours, ensuring that at least one staff member (Nurse/Skilled
Birth Attendant/Doctor) was available in the maternity unit most of the time. Close to half of
the women were visited by a nurse or doctor at least once during their stay. The examination
was limited to verbal enquiry of general condition of the baby and mother, and checks of
blood pressure and postpartum bleeding. Only some women received counselling on essential
postnatal care that focused mainly on exclusive breastfeeding, immunization and family plan-
ning. The number of women counselled for danger signs of mother’s and baby’s health were
very few. A few women faced verbal abuse (talking roughly) during the postnatal period. Few
providers were seen demanding informal payments. Box 3: reflections pointing to an instance
of poor post-delivery newborn care provided to one of the cases being observed.
Table 1. Clinical and non-clinical indicators: Direct observation of women (N = 23) in study facilities.
Stages Indicators
Pre- Delivery 1. Initial examination done within 15 minutes after registration (Most)
2. Provider evaluate blood pressure (Some); pulse (Few); temperature (Few)
3. Provider evaluate test for glucose in urine (None)
4. Provider evaluate test for haemoglobin (None)
5. Determine position of fetus (Most)
6. Determine fetal Heart rate (Some)
7. Care provider wash hands before examination (Few)
8. Cleaning of woman’s perineum before examination (Few)
9. Woman’s privacy maintained during the physical examination (Many)$
10. Woman informed about labour progression (Many)$
11. Have to wait at the observation ward (Many)$
Delivery 12. Women left alone at any point (Some)$
13. Use box of sterile instruments for each delivery (Some)
14. Monitoring of labour-Record keeping in partograph (None)
15. Motivated woman to push the baby (Most) $
16. Administers uterotonic (All); before delivery (Many); after delivery (Many)
17. Performs uterine massage immediately following the delivery of the placenta (Many)
18. Someone present during delivery to provide support (All) $
19. Woman face any abuse during labour (Few) $
20. Takes mother’s vital signs 15 minutes after birth (Some)
21. Palpates uterus 15 minutes after delivery of placenta (Some)
22. Disposal of all contaminated waste in leak-proof containers (Most)
23. Disinfect cord (Most)
24. Immediate skin-to-skin contact (Many)
$
-Non Clinical indicators.
The table lists critical clinical and non-clinical indicators performed by providers for all 23 cases that were observed.
These have been classified as ‘None (0%); few (below 25%); some (25–49%); many (50–74%); most (above 74%) and
all (100%) and discussed under two stages of—pre-delivery and delivery.
https://doi.org/10.1371/journal.pone.0204607.t001
Quality of maternal care during childbirth in India
PLOS ONE | https://doi.org/10.1371/journal.pone.0204607 September 27, 2018 10 / 20
Stage 5: Discharge
The fifth stage of observation was the discharge process, in which the women filled the Janani
Suraksya Yojna form to claim their financial incentive. At the time of discharge the staff usu-
ally vaccinated the babies, counselled the women on postnatal care and dispensed medicines.
Across facilities, the staff nurse completed most of the discharge formalities except JSY paper
work and arrangement for transport, which was done by the CHWs. A few women were coun-
selled at their bed side. All others were counselled in the nurse duty room while the baby was
being vaccinated. The counselling mainly focused around immunization; family planning and
exclusive breastfeeding. Identifying the baby’s and mother’s danger signs was the least dis-
cussed topic. Most women and their companions were given information on the immuniza-
tion schedule, whereas only some of them received instructions for follow-up check-ups. Close
to half of the women did not receive free medicines and cotton/sanitary pads at the time of dis-
charge. Informal payments were demanded from a few women at the time of discharge.
Discussion
This paper describes the findings of the quality of maternity care provided in primary and sec-
ondary level public health facilities in two districts of UP, India. Direct, non-participant obser-
vations were used to capture the critical components of both clinical as well as non-clinical
obstetric care from admission through discharge. Door-to-door observation of the entire jour-
ney of a woman’s experience of delivery care allowed identification of critical gap areas specific
to each of the five stages. Few other studies have similar in-depth documentation [22,27,46–
48]. These studies were conducted in similar settings—Ethiopia; Nigeria; UP and MP in India
and most of them used direct observations of intrapartum care provided during labour and
childbirth except one in Nigeria that employs a different qualitative approach to capture the
experiences of providers and women. Good practices, as well as gaps, were observed at each
stage of delivery care. Most gaps were noted during delivery and pre-delivery stage, most strik-
ingly on patient safety and the clinical process of care. Overall, though human resources and
infrastructure were available across all facilities, five key areas of concern were identified: inad-
equate clinical care and patient safety, information sharing, compromised privacy, disrespect-
ful care and informal payments.
Box 3. Post- delivery care
It was a breech baby. The baby was born with some deformity in the feet and did not cry
soon after birth therefore the nurse started the resuscitation process. The baby was
shifted to the Newborn Stabilization Unit and was placed in a baby warmer. The nurse
started reviving the baby with the help of ambubag. She tried to inject 5 ml calcium glu-
conate mixed in 5 percent dextrose in the cord of the baby but the cord clip was clamped
too close to the navel of the baby leaving no space for injecting the drug. When injecting
the drug through the cord failed, the doctor (on emergency duty) advised for injecting
the drug via catheter. It took almost close to 10 minutes for the nurse to find a surgical
tape before preparing a catheter opening, which also did not work. Next, the team
started aspiration using mucus extractor. The baby could not be revived and seeing the
baby unresponsive the doctor decided to refer the baby to the nearby district hospital
but soon the baby died. After completing the final investigation the doctor informed the
family and mother about death of the baby.
Quality of maternal care during childbirth in India
PLOS ONE | https://doi.org/10.1371/journal.pone.0204607 September 27, 2018 11 / 20
Table 2 summarizes key good practices and areas of concern noted in the observations
across five stages of delivery care. Most gaps were identified during the ‘delivery stage’. ‘Clini-
cal process of care’ and ‘patient safety’ during pre-delivery and delivery stages were the key
areas of concern where gaps were noticed in the quality of care provision. Gaps were observed
in other areas of care provision that included information sharing, maintaining privacy, pro-
viding emotional support and demanding informal payment. Structural gaps—infrastructure
and human resource provision were not as startling as the areas included in the ‘process’ of
care.
First, there were a number of gaps in clinical process of care. Study findings suggest that
routine monitoring of labour such as use of partograph, fetal heart rate monitoring, blood
pressure, temperature and pulse rate were not being performed by all providers uniformly.
Providers in some cases administered uterotonic prior to delivery for inducing labour pains
[49,50], which is not consistent with national and global guidelines [51]. Similarly, some of
the essential care practices during third stage of labour and immediate post-partum period like
controlled cord traction, palpation of uterus, and assessment for perineal and vaginal lacera-
tions, were not performed for most cases. This has also been observed in other studies [52–54].
According to a hospital-based cross-sectional study conducted in Netherland the active third
stage management was being adequately performed in only close to half of all vaginal deliveries
[54]. Other gaps include inappropriate maternal and newborn infection management, not pro-
viding immediate skin to skin contact and no assessment of newborn’s health [22,46,55].
Gaps in patient safety included providers not performing hand hygiene before wearing sterile
gloves, instruments not being sterilized; and improper disposal of sharps. Similar evidence has
been found in other studies conducted in India [22,55,56].
Lack of information, privacy, and emotional support were the other key gap areas in the
process of care. Patient-provider interaction and information sharing was limited in terms of
content, quantity and quality. Establishing a two-way communication with the woman, mak-
ing her a receptive and active participant in improving the process of care, is often a neglected
aspect of delivery care provision [28,57,58]. Other studies in conducted in Malawi and Haiti
have observed sharing inadequate information on postpartum care, specially information on
danger signs [59,60]. In terms of maintaining privacy, though entry of males was restricted in
all labour rooms, use of drapes and screens for providing privacy to the labouring women was
not practiced, corroborating findings from other studies [27,29]. Findings from a five country
study conducted in health facilities in Africa points out women experiencing compromised
auditory and visual privacy resonating well with our findings [27].
Recent reports from many low- and middle–income countries suggest that women are
being denied labour companionship, especially during childbirth [27,28]. However, we did
not find any such restrictions in our study and our findings were consistent with other studies
in India [18,29]. All women were allowed to have at least one female companion along with
the CHW throughout labour and delivery. Several studies have highlighted women experienc-
ing abandonment and neglect during childbirth [29,61,62]. Our study also found that some
women were left unattended in the delivery room after childbirth for more than 15 minutes.
Although few in number, there were instances of women experiencing both verbal and physi-
cal abuse at the hands of the provider, mostly during labour and delivery. Similar experiences
of disrespectful maternal care including pushing, slapping, shouting, threatening women for
refusal to treatment, and unwarranted fundal pressure have been reported in studies from
other developing countries including India [22,27,28,61].
Informal payments was also a concern in these facilities. JSY guarantees women delivering
at any government institution free delivery care along with monetary incentives. However,
research has highlighted issues of informal payments and other out-of-pocket expenditure
Quality of maternal care during childbirth in India
PLOS ONE | https://doi.org/10.1371/journal.pone.0204607 September 27, 2018 12 / 20
Table 2. Summary of areas of concern and good practices observed in the study.
Themes of care Good practice Areas of concern
Infrastructure Admission
Signboards showing registration counter; Ramp way clear; defined
waiting area with seating arrangement; drinking water and power
supply (with backup)
Pre-delivery
Adequate beds and delivery tables
Post-delivery
Adequate beds available for all women and babies
Discharge
Free transport for home arranged
Admission
No stretcher or wheelchair provided to take women to labour room.
Post-delivery
Adequate seating and sleeping arrangements not available for companions
Human Resource Delivery
All deliveries conducted by skilled provider (mostly staff nurse)
Post-delivery
Security guard not present to regulate visitors in PNC ward
Supplies - Delivery
Family members arranged for medicine/cotton
Discharge
Women did not receive medicines; pads/cotton
Clinical Process
of Care
Delivery
Sterile surgical gloves used for examination of most women
Pre-delivery
Incomplete initial examination—blood pressure; pulse; temperature;
hemoglobin and glucose in urine and fetal heart rate not conducted for
close to half of the women
Delivery
• Partograph not filled during and after delivery
• Administration of uterotonic (oxytocin 1ml to 3 ml) prior to delivery—
inducing labour pains
• Skin not disinfected before giving injection;
• Perineal and vaginal lacerations not assessed;
• Vital signs not taken 15 minutes after delivery;
• Uterus not palpated 15 minutes after delivery of placenta;
• Immediate skin-to-skin contact not established
• Vaginal packing and giving unwarranted fundal pressure (Most cases)
• For most babies, temperature and skin color not monitored 15 minutes
after birth and vitamin K not administered
• Lining the uterus with mustard oil before delivery (Few cases)
• Cleaning the baby’s body and inside of the mouth with mustard oil (Few
cases)
• Keeping the baby uncovered until cord cutting and weighing (Few cases)
• While using the mucus extractor Mothers asked to suck from one end
while inserting the tube in baby’s mouth and nostrils (Few cases)
Post-delivery
No examination conducted (including blood pressure) and most babies
were not examined in PNC ward
Patient Safety Delivery
Disposal of all contaminated waste in leak-proof containers Pre-delivery
• Hand hygiene and cleaning women’s perineum before examination
nearly absent
• Using condom for conducting per vaginal examination (Few cases)
• Used gloves left on the delivery table close to the patient (Few cases)
Delivery
• Hand hygiene not performed before any examination; sharps not
disposed properly and immediately after use; sterile supplies (gloves,
cotton; blade; tray) not used for some deliveries
• The broken (used) oxytocin vials were thrown on the floor
(Continued)
Quality of maternal care during childbirth in India
PLOS ONE | https://doi.org/10.1371/journal.pone.0204607 September 27, 2018 13 / 20
negating the benefit of the monetary incentive provided by the state [14,30,63–65]. While we
observed that informal payments were demanded in a few cases, it is possible that the extent of
informal payment demanded by the staff is underreported since our presence may have altered
their behavior. We also found that providers in many facilities also insisted that patients and
their families purchase drugs from private pharmacies located close to the facility, though sup-
plies were available in most facility.
Over the past years there has been a growing pool of evidence from across the globe sug-
gesting that until a satisfactory level of quality is attained in service delivery, the desired and
Table 2. (Continued)
Themes of care Good practice Areas of concern
Information
Sharing
Pre-Delivery
Women were told how far they were in labour
Pre-delivery
Women or family members not able to ask question to the providers
Post-delivery
• Information about mother’s and baby’s health not shared with
companions;
• Counseling on breastfeeding and thermal care not provided
• Danger signs not discussed
Discharge
Women were not counselled on family planning; immunization; exclusive
breast feeding; baby’s and mother’s danger sign and instructions for follow-
up check-ups not given
Emotional
support
Delivery
Female companions allowed in labour room
Post-delivery
Companions stayed throughout in the PNC ward
Delivery
• No support in helping women climb on the delivery table;
• Women left alone in the delivery room post-delivery for more than 15
mins
Privacy Delivery
Most women not exposed unnecessarily during delivery
Delivery
Dividing screen/curtain between delivery tables not available in labour
rooms
Post-delivery
Male visitors were present in the PNC ward at all times
Respectful Care - Delivery
Women faced verbal and/or physical abuse during labour (few cases)
Promptness Pre-delivery
PV and abdominal examination conducted within 15 minutes of
reaching the facility for all women
Post-delivery
• Women were kept under observation in labour room for more
than an hour before shifting to PNC ward
• JSY paper work completed before discharge
Post-delivery
Women not visited by provider at least once in three hours
Cleanliness - Post-delivery
• Cots/bed sheets were not clean
• Toilets and bathrooms not clean
Informal
Payments
Pre-delivery
No provider asked for informal payment
Delivery
Providers asked for money to the accompanied person (few cases)
Post-delivery
Out-of-pocket expenditure for services including medicines; informal
payment; photograph for JSY (few cases)
Abbreviations: PV Per Vaginal; PNC Post Natal Car; JSY Janani Suraksha Yojana
The table lists ‘good practices’ and key ‘areas of concern’ as per the Indian Public Health Standards guidelines for Primary and Community health centres, 2012. These
have been discussed under five stages of delivery care—admission; pre-procedure; procedure; post-procedure and discharge and further categorized into themes of
quality care framework.
https://doi.org/10.1371/journal.pone.0204607.t002
Quality of maternal care during childbirth in India
PLOS ONE | https://doi.org/10.1371/journal.pone.0204607 September 27, 2018 14 / 20
expected reductions in maternal mortality cannot be achieved only by improving infrastruc-
ture, accessibility and incentivizing institutional delivery [22,33,66]. In India, the current
quality assurance guidelines have shifted focus from not only ensuring facility infrastructure,
but also addressing measures to ensure patient privacy, increasing patient information and
engagement, and setting up a system of grievance redress in the form of Patient Welfare Com-
mittee [18]. Our findings have the following policy implications in order to make the health
system more outcome driven and responsive to patient’s needs, aspects such as promptness,
information sharing and respectful behaviour need to be incorporated in the policies [32,33].
Studies have highlighted that challenges deterring optimal utilization of facilities includes lack
of adherence to clinical protocols; compromised patient safety; women-friendly delivery envi-
ronment; cognitive support; compromised privacy; frequent abuse and demand for informal
payments [22,29]. Identifying and addressing structural gaps, training and orientation of staff
towards aspects of person-centered care, and adherence to clinical protocols through crite-
rion-based audits needs to be prioritized and implemented [33,67]. Training and orientation
of staff towards aspects of person-centred care including respectful & supportive care; infor-
mation sharing; effective communication skills and patient privacy can go a long way in sensi-
tizing providers around person-centred care, supported by public display of behavioural
norms in the charter of patient rights and entitlements. The findings from a quality improve-
ment (QI) intervention in public health facilities across six states of India, suggest that simple
QI methods like redesign of space and task shifting have the potential to improve quality of
facility-based routine clinical practices in resource poor settings like India [62] QI cycles may
be followed by performance based grading of facilities on attainment of specific quality bench-
marks to encourage adoption of good care practices. A concept of ‘positive deviance approach’
may also be introduced for collating and sharing ‘best practices’ with regards to quality of care
in facilities performing better while having access to the same resources and facing similar or
worse challenges.
Limitations
One of the key limitations common to observational studies is that staff actions may have been
influenced by the presence of the observers. To minimize this bias, the investigators spent a
day in the facility familiarizing themselves with the setting and interacting with the staff before
beginning to record the observations. We assumed that this would put the staff at ease with the
team by the time the observations began; however, we acknowledge this potential bias remains.
The second limitation of the observation method is the observer’s bias in data collection and
interpretation of results. We worked to mitigate this by using a standardized checklist to
record the data across the team and triangulating the findings of multiple observers.
Conclusions
It is encouraging to witness developing countries like India slowly realizing the need and
importance of improving quality of care in public health facilities in order to make care more
responsive to women’s needs. Findings from this study reflect gaps in the ‘quality front’ of
maternity care provision in public health facilities in India and our results support the argu-
ment for strengthening maternity care services provided by the public health system.
Identifying and addressing structural gaps including infrastructure and medical supplies
should be prioritized [34], followed by gaps related to ‘process of care’ including clinical care;
patient safety; information sharing; emotional support; informal payments; and disrespectful
care. Staff training is required on aspects of person-centered care such as therapeutic commu-
nication. Clinical supervision of staff; criterion-based audits; near-miss audits; and supportive
Quality of maternal care during childbirth in India
PLOS ONE | https://doi.org/10.1371/journal.pone.0204607 September 27, 2018 15 / 20
supervision should be undertaken for ensuring adherence to clinical care protocols and quality
norms [34,67]. There is evidence that simple Quality Improvement methods like redesigning
of space and task shifting have the potential to improve quality of facility-based routine clinical
practices in resource-poor settings like India [62]. Appreciating positive deviance and recog-
nizing quality of care ‘best practices’ could also encourage facilities to optimize quality within
the given resources.
Supporting information
S1 Table. Profile of study facilities by provider and infrastructure provision. Acronyms:
CHC-Community Health Centre; PHC-Primary Health Centre; BPHC-Block Primary Health
Centre; FRU-First Referral Unit; ANM-Auxiliary Nurse Midwife. Source:
$
Observation
data and departmental Health Management Information System (HMIS) records, Sep 2016.
Description of data: The table gives information about profile of the study facilities including
facility type; number of in-position staff in the maternity unit; available infrastructure facilities
and patient load for vaginal and caesarean deliveries for the month of September 2016.
(DOCX)
S2 Table. Checklist for facility observation.
(DOCX)
Acknowledgments
We would like to acknowledge the contributions of the participating investigators—May Sud-
hinaraset; Nadia Diamond Smith; Katie Giessler and Dominic Montagu in performing techni-
cal editing of the manuscript; Mousumi Gogoi for participating in data collection and data
curation; Tanuja Mehra, Nidhi Pandey and Ruchi Yadav for participating in data collection.
Author Contributions
Conceptualization: Aradhana Srivastava, Sanghita Bhattacharyya.
Data curation: Malvika Saxena, Aradhana Srivastava.
Formal analysis: Malvika Saxena, Aradhana Srivastava, Sanghita Bhattacharyya.
Investigation: Malvika Saxena, Pravesh Dwivedi.
Methodology: Aradhana Srivastava, Sanghita Bhattacharyya.
Project administration: Pravesh Dwivedi.
Supervision: Aradhana Srivastava, Sanghita Bhattacharyya.
Visualization: Aradhana Srivastava, Sanghita Bhattacharyya.
Writing – original draft: Malvika Saxena, Aradhana Srivastava, Sanghita Bhattacharyya.
Writing – review & editing: Malvika Saxena, Aradhana Srivastava, Pravesh Dwivedi, Sanghita
Bhattacharyya.
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